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Proximal vs Distal Case and orthoses prescription.

Discussion in 'Biomechanics, Sports and Foot orthoses' started by pod6, Oct 22, 2007.

  1. pod6

    pod6 Member

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    Hi all,

    Pod student here:

    Helping a friend out who has been recommended by a sports physician and his physio for custom made foot orthoses. He has had a history of:

    - Chronic undiagnosed high ankle pain secondary to trauma (kicking the ground instead of the football!!:bang:)

    - Acute and chronic posterior knee problems.

    I believe the aim is to improve the distal biomechanics in an aim to improve proximal pathologies.

    A biomechanical and postural assessment indicated:

    - Lordotic curvature of lower back, associated anterior displacement of hip, poor hip flexor flexibility. Poor internal hip rotation. When standing in double supports both knees are hyper extended most likely secondary to lordosis. High Q angle and genu valgum. LLD of between 1-2 cms. External tibial torsion. Glute medius weakness more so on Right side (longer limb) posterior lower limb muscles tight.

    - STJ rom was quite diminished however maintained 3:1 proportion R/side more "stiff" than left side.

    - Supination resistance test was very hard to almost impossible. STJ axis medially deviated.

    - FHL present less than 40deg ROM.

    - Lateral heel strike followed by rear foot pronation throughout gait. No resupination.

    - Low gear toe off. Digital extension prior to toe off.

    - Angle and base of gait are normal

    - NCSP= about 1 deg inverted RCSP= 3 deg everted both feet. L/leg possibly more

    -arch during gait and whilst standing was low, however, did not collapse.

    - jacks test was also extremely hard

    My thoughts:

    - Lordosis, anterior pelvic displacement and associated hip pathologies due to tight hip flexors, and weak glutes/lower abs.

    - ? Tibial torsion due to high q-angle and genu valgum.

    - Medial STJ axis and inverted foot type due to genu valgum due to tibial torsion.

    - Low gear toe off due to decreased ROM of 1st MTPJ. Also explains digital extension prior to toe off.

    What to do??

    For an orthoses prescription I would like to see him in a rear foot device such as a DC wedge. With moderate 7 to 9 degree control. However, my concern is his reduced STJ rom, is this likely to be an issue with a rear foot device?

    How might I accommodate his reduced 1st MTPJ rom in both feet?

    am i on the right track??

    what I can’t work out

    To me it seems as though the majority of his problems arise from his hip flexor tightness. I.e. high q angle, genu valgum etc. it appears to run in the family (lordosis). I guess this is a chicken before the egg sort of question.

    Is the hip flexor tightness causing the distal complications or is it the distal problems causing the proximal complications?
  2. pod6

    pod6 Member

    my mistake.... replace functional HL with structural HL
  3. Atlas

    Atlas Well-Known Member

    My 5 cents worth is:

    1. What is the main problem with the patient? The chronic undiagnosed ankle or the posterior knees or both. If it is the former, then textbook biomechanical correction is unlikely to help IMO. Is ankle plantar-flexion full range and tolerated is one of several questions/findings that you would want to clear/check.

    2. Just because a sports physician and a physio think that custom orthotics should help doesn't necessarily mean anything. We get into the habit of thinking about the "hierarchy of health"; whereby a surgeon has a better understanding than a sports physician, who has a better understanding than a physiotherapist...and so on.

    The positive is that you have little to lose (like your friend) as a student in trying to make a pair to acheive a clinical outcome. So what is the worse thing that can happen?

    3. You have made a plethora of observations, but how many of them are relevant? As a student, you have done well to tick all these boxes (but with clinical experience you may work out that data overload may complicate a relatively simple presentation).

    Good luck; but to me too many questions remain about the chronic undiagnosed ankle. Has an MRI has been ordered?
  4. pod6

    pod6 Member

    MRI got the all clear.

    What pescription orthoses would you consider?

    What effect would his decreased STJ ROM have on you pescription?

    Would improvement of his hip alignment (and lordosis) improve his foot posture or vice versa?
  5. Can think of a few more questions, weight, sport, shoes etc but thought of trialling some softs first, custom heat mouldable orthoses with rearfoot varus control, control the rearfoot to help control the forefoot.
  6. Pod student 6:

    I see no mention of ankle joint dorsiflexion/stiffness. It sounds like this patient has genu recurvatum which is commonly associated with a gastrocnemius equinus deformity. Certainly also this patient has multiple other structural/functional pathologies. However, considering his genu recurvatum and posterior knee symptoms, try putting him into 6 mm heel lifts bilaterally while you are waiting to try to decide how to treat him. Heel lifts, or walking in shoes with higher heel height differential, will likely help relieve some of this posterior knee pain. A medial heel skive foot orthosis that increases the subtalar joint supination moment may help with his lack of resupination during gait. Also, putting him on hip flexor stretching exercises may help out his posture.
  7. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    The problem, my friend, is that you don't have a diagnosis.

    Treating the "biomechanics" might be alright for some, and may even prove to be benificial...yet, you haven't spoken at all about true physical assessment of the problem.

    Once you make the diagnosis, then treatment is the easy part.

  8. Craig Payne

    Craig Payne Moderator

    Good observation. I just finished explaining to a group of students that a biomechanical assessment is not part of the diagnosis. A biomechanical assessment is just there to determine if and what is the pathomechanics behind the diagnosis and to derive an orthoses prescription --- its not there to make the diagnosis with.
  9. Kent

    Kent Active Member

    I've seen a few patients come to me with this terrible diagnosis of "forefoot valgus".:bang:
  10. CraigT

    CraigT Well-Known Member

    In fairness, the patient was referred for a biomechanical assessment by a physio and sports physician and has had an MRI. The diagnosis is a work in progress. I think from the description that there is significant biomechanical concerns, so I do not think it is unreasonable to try to address these without the diagnosis.

    Agreed, but this is something that you should be making clear to the patient. I have no problem with the concept that I am 'treating biomechanics'. The important thing is that if you do not have a diagnosis, but you want to manage them, then the patient understands this and follows your rationale. There are many ways to test the links between the pathology and the biomechanics which can help also.
  11. pod29

    pod29 Active Member

    You have probably already assessed these but I will ask any way. Have you checked his ankle tib-fib syndesmosis. These injuries will often go undiagnosed. I would suspect that even a minor injury in this region will effect ankle joint stiffness( as kevin previously alluded to). A seconday issue that may arise from this would be proximal tib-fib joint dysfunction(and pain?).

  12. conp

    conp Active Member

    Hi Pod6,
    My guess is that if they have already seen a sports physician and a physio then it is quite possible that some over the counter insole/device has been tried. This should already give you a clue on how to treat.
  13. pod6

    pod6 Member

    he has seen a well known sports doc and his recomended physio.

    Basically the aim is not to develop a Dx, but to improve his biomechanics. I know this may not be an indication for orthoses issue, however, he is willing to give it a go for his own benefit and mine.

    He wears Kayanos for everything except football, he wears the all condition Nomis boots for AFL.

    as for his past knee history, he strained his medial ligament and also chipped some bone off his patella. 'bone brusing' was the dignosis for his high ankle pain...at the moment there is no problem with either of these injuries.

    my two main questions are:

    what prescription are you likley to use skive vs RF wedge.?? I am also a lil confused about how much correction to include, given his footwear and STJ rom.

    secondly, will distal biomechanical intervention aid in improving his proximal postrual issues?

    as for the heel lifts, would the lordosis be a contraindication for heel lifts, given that he reports some lower back pain??? (aftr speaking with him further today). his family has a history of back pain and share similar postural issues
  14. Peter

    Peter Well-Known Member

    I cannot see why you are trying to improve someones biomechanics when you do not have a diagnosis.

    For example, say this pt has injured his extensor retinaculum, and you lifted his heel to improve his biomechanics, would you be happy that his biomechanics is "improved", when he complains that his retinaculitis has worsened.

    Not having a personal shot, just wanted to know.
  15. Iain Johnston

    Iain Johnston Active Member

    Interesting case, perhaps all the info you derived has clouded what you are trying to acheive.
    This case sounds like a time bomb. He sounds like he has a lot of inherited features that he has compensatoed for for years and that have finally 'run out of' compensation.
    The ankle pain may be symptomatic of a foot that has breathed every last drop of pronation in a limited STJ and Mid Tarsal Joint, therfore has no where else to go but jamb the ankle.
    I have no doubt he has very poor ankle dorsiflexion, hense the potential to get some response with heel lifts.
    Try loosening up the calves as well, by placing a folded hand towel under the medial forefoot, while he pushes the wall keeping his leg straight. The towel will aid supporting the foot and assiting the strech, whilst releiving the stress on the ankle.
    This will help the posterior knee too.
    As for orthtoics ---mmmm, i would be very reluctant based on his limited ROM.

    Even a few degrees improvement may be sufficient to releive the stress.

    for what its worth


    Iain Johnston
    Private Practice
    the Surgery
    Chart Lane
  16. pod6

    pod6 Member

    i see what you are saying its the 'if it aint broke dont fix it approach'.

    i am sure a lot of you guys/girls on a daily basis deal with pts. who claim "i have flat feet" or "my feet roll in" ... these people are determined that orthoses are a must even without any symptoms. .

    this is a similar concern to my patient along with the fact he has received medical advice to pursue orthotic treatment.

    how do you deal with a patient like this?

    i can see ways orthses can: improve his gait pattern, possibly improve his posture (which no one is willing to comment on ;)), and for my sake have a go at prescribing and manufacturing some orthoses.

    being a keen and very active sportsmen i would have thought biomechanical improvement could be a very useful indication for orthoses prescription. He is only 16 years old, is another point.

    as for other interventions:

    I have recomended strectching for hipflexor , adductors, calf and lowerback
    strengthening of lower abs (or just abs), strengthening of his glutes and hamstrings.

    this treatment is from an article i read up on for the treatment of lordosis.
    Last edited: Oct 24, 2007
  17. I still have seen no mention of you evaluating this patient's ankle joint dorsiflexion with the knee extended and the knee flexed. This, or other ankle joint dorsiflexion assessment techniques, is one of the most important clinical measurements you can make in the exam of any patient.

    Also, there is no harm to give the patient custom foot orthoses, especially if the foot is abnormally pronated, and you expect the symptoms are being caused by increased STJ pronation moments. If they cause problems, then either adjust them or have him take them out of the shoe.

    Try the heel lifts.....what do you have to lose??
  18. pod6

    pod6 Member

    sorry kevin my mistake, he has tight gastroc and soleus muscles, i thought i mentioned it.

    how much correction would you consider kevin? i.e. how much of a skive? or how many degrees for a wedge? i would like to give him quite an aggressive device but due to his decreased STJ ROM i am a little reluctant.

    do you think heel lifts are contrainidicated due to his hip and back issues?
  19. Here is what I would do with this patient:

    1. Put him on three time a day gastroc and soleus, and hip flexor stretching exercises.

    2. Initially, put 1/4" (6 mm) korex heel lifts into his shoes for all sports and activities.

    3. Place varus heel and medial arch wedging on an over-the-counter (OTC) orthosis along with the heel lifts to see how he clinically responded.

    4. Try strapping his distal leg or use compressive wrap in distal leg to see if this makes symptoms improve (think interosseous membrane/retinaculum tear).

    5. If positive response is noted to modified OTC orthosis, make orthoses for patient: 3 mm medial heel skives, 18 mm heel cups, balanced 2-5 degrees inverted, with 3/16" (5 mm) polypropylene, 4/4 degree rearfoot posts, with or without extra heel contact point thickness (i.e. heel lifts) depending on response to heel lifts.

    6. As gastroc/soleus flexibility improves, gradually reduce heel lifts to patient tolerance.

    Ankle joint compression forces will be greatly increased with tightness in the gastroc-soleus which may be the cause of the patients high ankle pain (may be increasing the separation of the interosseous retinaculum?). Don't worry if you don't have a definitive diagnosis yet, however, you should have a differential diagnosis by which to guide your treatment. My first guess is a partial tear of a retinaculum, muscle or other soft tissue structure of the "high ankle" due to the kicking injury that is being continually being over-stressed by his abnormal mechanics and activities.

    You need to get out your anatomy book, and start examining the patient to see what anatomical structure is most tender to palpation/increased stresses. This will help the patient, you and us out immensely.
  20. CraigT

    CraigT Well-Known Member

    It is interesting to read the different approaches that people on this forum have to this problem...
    As a student it is a good opportunity to nut through some difficult problems- the key here is what Atlas said-
    The first question would be- what do you want to achieve with the orthosis. Directly answering your question with respect to ROM issues- if you try to apply too much rearfoot control you will find that the foot will not sit on the orthosis as you would wish. In the case of a DC wedge, the heel will shift laterally in the shoe and blow out the upper. A skive device with a deep heel cup will counter this to a degree, but you can still run into the problem of 'irresistable force vs the immovable object'. Addressing the limited dorsiflexion via the stretching as Iain suggested and heel lifts is of paramount importance.
    As for the the effect on proximal posture- difficult to say with certainty. I have had patients similar to this whose posture has significantly improved with improved control of lower limb function. You would probably be well served consulting with the physiotherapist also- they have more experience with addressing issues such as lumbar lordosis, and can probably help with respect to tolerance of any changes that you may make.
    If you want to experiment a little- low dye tape with a heel lift.
  21. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    My exact point.

    Whilst I am the first to raise my hand as being guilty of treating the biomechanics rather than the pathology, as an educational exercise for this student I would like to see some attempts made at a differential diagnosis, based on the most likley anatomical structures involved.

    Then we can all sit around and come up with a sexy intellectual way of making the biomechanics fit the diagnosis.

    Whatever happened to presenting a case study with at least "cutaneous, vascular and neurological structures are within normal limits" - that helps us at least rule out about 80% of the conditions this could be....?

    (Admin should set some basic guidelines for presenting cases on this forum me thinks):(

  22. pod6

    pod6 Member


    I am looking at this from a pure biomechanical view. I could sit here with an anatomy text and rattle off every possible problem in the local area. I bet you that an AFL club doctor and his partner in crime (the physio) would have done much the same already, not to say i wouldnt have a go myself.

    I am more interested in correcting his foot and proximal biomechanics/ posture, with an orthoses prescription.

    If i dont mention vascular, cutaneous or neuro. I think its pretty safe to assume that everything is normal in a 17yr old boy.
  23. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    And someone else might look at this from a purely neurological point of view. Or a rheumatology point of view.

    Young padawan - I'm not trying to labour the point, but it is just good basic medical practice to do a systems review, and report findings - adverse or otherwise, when presenting a case for review by peers.

    Once you've been around for a few years, and had a couple of threats for law suits, I think you will be more likely to *not* assume that just because a 17yo presents then they will have normal basic findings. Tell that to a court when you miss an undiagnosed young Buergers disease patient that calls in on Monday morning with a sore foot after weekend footy. From experience, if the sports physician and physio are having difficulty with the case, then it is even more critical to get back to basics to make sure nothing has been missed.

    Have you ever been on Grand Rounds? If not, you owe it to yourself to get down to your local teaching hospital and get on the consultants rounds to appreciate the point I am making.

    I/we still have no idea what structures are painful, and which are not, so for all we know this may have absolutely nothing to do with biomechanics at all!:rolleyes:

    Throw us a little more that orthopaedic/biomechanical observations, which are just one facet of the patient, and you may get some more useful information from out of your peers.



    Jill: My joints have been feeling all loose, and lately I've been feeling sick a lot. Maybe I'm overtraining; I'm doin' the marathon, like, ten miles a day,
    [House looks tired]
    Jill: but I can't seem to lose any weight.
    Dr. Gregory House: Lift up your arms.
    [she does so]
    Dr. Gregory House: You have a parasite.
    Jill: Like a tapeworm or something?
    Dr. Gregory House: Lie back and lift up your sweater.
    [she lies back, and still has her hands up]
    Dr. Gregory House: You can put your arms down.
    Jill: Can you do anything about it?
    Dr. Gregory House: Only for about a month or so. After that it becomes illegal to remove, except in a couple of states.
    [he starts to ultrasound her abdomen]
    Jill: Illegal?
    Dr. Gregory House: Don't worry. Many women learn to embrace this parasite. They name it, dress it up in tiny clothes, arrange playdates with other parasites...
    Jill: Playdates?
    Dr. Gregory House: [shows her the ultrasound] It has your eyes.
    [it's a baby]

    Last edited: Oct 25, 2007
  24. pod6

    pod6 Member


    agree with what ur saying. iit would be foolish on ur part not to baseline testing even if every other medical professional had already done them.

    forget pain or symptoms! i only ever said he had a history of these problems. Purely on the basis that he is my mate and my guniea pig, i would like to try some orthoses, not to fix and aches and pains. but in an attempt to improve his posture and biomechanics.

    i know it would be a great exercise for me to list every pathology under the sun for a given anatomical location. but in this case i am curious about developing my orthoses prescription skills.

    what im trying to say is you have patient X with Y biomechanical anomalies. If you were to prescribe a device what would it be?
  25. Pod6:

    Next time you want to experiment on one of your friends, please let us know before hand that this is not a real patient so that we don't waste our valuable time giving you recommendations on how to treat a person who doesn't have any complaints.:bang:
  26. Is it an art or a science? There are lots of ways to skin a cat and no one has even died from orthotic's yet, its not rocket science, sometimes just common sense. Many years ago I ran a marathon with my orthotics placed in the wrong shoes - ran a Personal Best time, however it did catch up with me and 50 marathons later I am still running.
  27. efuller

    efuller MVP


    I agree with Kevin's prescriptions.

    The limited STJ ROM would have no effect on my prescription. In gait we use very little of the total range of motion. Any thing that creates a varus heel wedge effect could be used with a person with a medially deviated STJ axis.

    Limited range of motion does effect my prescription when I am deciding whether or not to add a forefoot wedge (varus or valgus). The measurement I perform, I call maximum eversion height. With patient standing in angle of base of gait the patient is asked to evert their foot without "moving their knees" or moving their tibia relative to the ground. With this test you will see people who have 3 cm range of motion ranging down to zero range of motion. Do not attempt to put a forefoot valgus wedge under someone's foot if they have zero range of motion with this measurement. Do not try to evert the foot farther than it can go. If you ask a lab to balance a cast to vertical when the lab sees a forefoot valgus in the cast will give you a forefoot valgus wedge. As a student, how wedging gets into your finished orthosis is very important to understand.

    Regarding distal orthoses effecting proximal pathology. Howard Dannenberg has publlished on how foot function can effect low back pain. I have seen this anecdotally, but I disagree with Howard's explanation of why this works. My explanation is related joint power. Joint power is the amount of energy gained or lost from muscle activity and is equal to joint moment x joint angular velocity. When walking energy has to be added to the swing leg so that it can catch up and pass the body. There are two choices for adding energy to the swing leg. There is ankle joint push and hip joint pull. Winter has shown that there is an inverse correlation of hip pull and ankle push. This makes sense because you only need a certain amount of energy to make the leg swing and if you have a lot of power from one source you only need a little power from the other source.

    In looking at people with "sagittal plane blockade" they have very little ankle push because there is little ankle plantar flexion and when there is little plantar flexion there will be little power because the angular velocity will be low. (Think of the equation for ankle joint power) Therefore if there is little ankle joint push there must be a higher amount of hip pull. One of the major muscles contributing to hip pull is the Illio psoas which originates from the low back and will compress the vertebra of the lower back when it contracts. So, if your orthosis leads to an incrase in ankle push there will be a decrease in need for hip pull and less compression of the vertebra. This is a plausible explanation of how orthoses can improve low back pain.


    Eric Fuller

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